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Mabelle Makary
• Epidemiology incidence
– 4-6% of all fractures
– third most common non-vertebral fracture pattern
seen in the elderly (>65 years old)
• demographics
– 2:1 female to male ratio
– increasing age associated with more complex
fracture types
• Pathophysiology
mechanism
– low-energy falls
• elderly with osteoporotic bone
– high-energy trauma
• young individuals
• concomitant soft tissue and neurovascular injuries
• pathoanatomy
– pectoralis major displaces shaft anteriorly and medially
– supraspinatus, infraspinatus, and teres minor externally rotate greater
tuberosity
• arterial injury
– uncommon (incidence 5-6%), higher likelihood in
older patients
– average neck-shaft
angle is 135 degrees
• Vascular anatomy
– anterior humeral circumflex artery
• large number of anastamoses with other vessels in the proximal humerus
• branches
– anterolateral ascending branch
» is a branch of the anterior humeral circumflex artery
– arcuate artery
» is the terminal branch and main supply to greater tuberosity
– posterior humeral circumflex artery
• recent studies suggest it is the main
blood supply to humeral head
Classification
• AO/OTA organiz
es fractures into
3 main groups
and additional
subgroups
based on
– fracture
location
– status of the
surgical neck
– presence/abse
nce of
dislocation
• Neer
classification based on
anatomic relationship
of 4 segments
– greater tuberosity1
– lesser tuberosity3
– articular surface2
– shaft4
• considered a separate
part if
– displacement of > 1
cm
– 45° angulation
Neer Classification
Minimally Articular
Two Part Three Part Four Part
Displaced Segment
Anatomical
Neck
Surgical Neck
Greater
Tuberosity
Lesser
Tuberosity
Fracture-
Dislocation
Head Split
Evaluation
• Symptoms
– pain and swelling
– decreased motion
• Physical exam
– inspection
• extensive ecchymosis of chest, arm, and forearm
– neurovascular exam
• axillary nerve injury most common
– determine function of deltoid muscle (axillary n.)
• arterial injury may be masked by extensive collateral
circulation preserving distal pulses
– examine for concomitant chest wall injuries
Imaging
• Radiographs
• recommended views
– complete trauma series
• true AP (Grashey)
• scapular Y
• axillary
• additional views
– apical oblique
– Velpeau
– West Point axillary
• Findings
• combined cortical thickness (medial + lateral
thickness >4 mm)
– studies suggest correlation with increased lateral
plate pullout strength
• pseudosubluxation (inferior humeral head
subluxation) caused by blood in the capsule
and muscular atony
• CT scan
– indications
• preoperative planning
• humeral head or greater tuberosity position uncertain
• intra-articular comminution
• MRI
– indications
• rarely indicated
• useful to identify associated rotator cuff injury
Treatment
• Non-operative
– sling immobilization followed by progressive rehab
• indications
– most proximal humerus fractures can be treated non-operatively including
» minimally displaced surgical and anatomic neck fractures
» greater tuberosity fracture displaced < 5mm
» fractures in patients who are not surgical candidates
– additional variables to consider
» age
» fracture type
» fracture displacement
» bone quality
» dominance
» general medical condition
» concurrent injuries
• technique
– start early range of motion within 14 days
• Operative
– CRPP (closed reduction percutaneous pinning)
• indications
– 2-part surgical neck fractures
– 3-part and valgus-impacted 4-part fractures in patients with good bone
quality, minimal metaphyseal comminution, and intact medial calcar
• outcomes
– considerably higher complication rate compared to ORIF, HA, and RSA
– ORIF
• indications
– greater tuberosity displaced > 5mm
– 2-,3-, and 4-part fractures in younger patients
– head-splitting fractures in younger patients
• outcomes
– medial support necessary for fractures with posteromedial comminution
– calcar screw placement critical to decrease varus collapse of head
• intramedullary nailing
– indications
• surgical neck fractures or 3-part greater tuberosity fractures in
• younger patients
• combined proximal humerus and humeral shaft fractures
– outcomes
• biomechanically inferior with torsional stress compared to plates
• favorable rates of fracture healing and ROM compared to ORIF
• arthroplasty
– indications
• hemiarthroplasty
– controversial when considering hemiarthroplasty versus RSA
– younger patients (40-65) with complex fractures or head-splitting components
likely to have complications with ORIF
– recommended use of convertible stems to permit easier conversion to RSA if
necessary in future
• reverse total shoulder
– low-demand elderly individuals with non-reconstructible tuberosities and poor
bone stock
– low-demand patients with fracture dislocation
• Outcomes
• improved results if
– anatomic tuberosity reduction and healing
– restoration of humeral height and version
• poor results with
– tuberosity nonunion or malunion
– retroversion of humeral component > 40°
Treatment by fracture type
Two-Part Fracture
Surgical Neck • Most common fx pattern Nonoperative
• Deforming forces: • Closed reduction often possible
1) pectoralis pulls shaft anterior and • Sling
medial 2) head and attached tuberosities Operative
stay neutral • indications controversial
• technique
- CRPP
- Plate fixation
- IM device
Greater tuberosity • Often missed Nonoperative
• Deforming forces: GT pulled superior and • indicated for GT displaced < 5 mm
posterior by SS, IS, and TM Operative
• Can only accept minimal displacement • indicated for GT displacement > 5 mm
(<5mm) or else it will block ER and ABD - isolated screw fixation only in young with
good bone stock
- nonabsorbable suture technique for
osteoporotic bone (avoid hardware due to
impingement)
- tension band wiring
Surgical neck and LT • Unopposed pull of posterior cuff •Trend towards nonoperative
musculature leads articular surface to point management given high complications with
anterior ORIF
• Often associated with longitudinal RCT • Young patient
- percutaneous pinning (good results, protect
axillary nerve)
- IM fixation (violates cuff)
- locking plate (poor results with high rate of
AVN, impingement, infection, and malunion)
• Elderly patient
- hemiarthroplasty with RCR or tuberosity
repair vs. reverse total shoulder arthroplasty
a
b c
Four-Part Fracture
Valgus impacted fracture • Radiographically will see alignment • Low rate of AVN if posteromedial
between medial shaft and head component intact thus preserving
segments intraosseous blood supply
• Surgical technique
1. raise articular surface and fill
defects
2. repair tuberosities
4-part with head-splitting fracture • Characterized by high risk of AVN • Young patient
(21-75%) - ORIF vs. hemiarthroplasty
• Deforming forces: (hemiarthroplasty favored for
1) shaft pulled medially by pectoralis nonreconstructible articular surface,
severe head split, extruded anatomic
neck fracture)
• Elderly patient
- hemiarthroplasty v. reverse total
shoulder arthroplasty
Techniques
• CRPP (closed reduction percutaneous pinning)
– approach
• percutaneous
– technique
• use threaded pins but do not cross cartilage
• externally rotate shoulder during pin placement
• engage cortex 2 cm inferior to inferior border of humeral head
– complications
• with lateral pins
– risk of injury to axillary nerve
• with anterior pins
– risk of injury to biceps tendon, musculocutaneous n., cephalic vein
• possible pin migration
2 part proximal
humerus fracture
Axillary
ap
• ORIF approach
– anterior (deltopectoral)
– lateral (deltoid-splitting)
• increased risk of axillary nerve injury
• technique
– heavy nonabsorbable sutures
• (figure-of-8 technique) should be used for isolated greater tuberosity fx
reduction and fixation (avoid hardware due to impingement)
– isolated screw
• may be used for greater tuberosity fx reduction and fixation in young patients
with good bone stock
– locking plate
• screw cut-out (up to 14%) is the most common complication following
fixation of 3- and 4- part proximal humeral fractures and fractures treated
with locking plates
• more elastic than blade plate making it a better option in osteoporotic bone
• place plate lateral to the bicipital groove and pectoralis major tendon to
avoid injury to the ascending branch of anterior humeral circumflex artery
• placement of an inferomedial calcar screw(s) can prevent post-operative
varus collapse, especially in osteoporotic bone
Head splitting fracture of the proximal humerus
• Adhesive capsulitis
• Posttraumatic arthritis
• Infection
Thank you